الفهرس 
ANATOMYOnly 14 pages are availabe for public view
 |  | from | 172 |  |  |
| | | from | 172 | | |
Abstract
LA has become the treatment of choice to remove benign functioning and non-functioning tumors of the adrenal glands. Compared with open procedures, the data revealed that LA was associated with significantly less blood loss, shorter postoperative hospital stay and earlier oral intake. Multiple retrospective comparative studies and case series have confirmed these benefits of minimally invasive surgery for adrenal tumors.
LA also has advantages such as better cosmetic, use of fewer analgesics, higher patient satisfaction, decreased morbidity, and markedly better economics, shorter hospital stay with reduced hospital costs and earlier return to regular work and activities.
More than 75% of LAs are performed to treat endocrine causes of hypertension such as aldosteronoma, Cushing’s syndrome and disease, and pheochromocytoma.
In a study, 34.1% of patients had aldosteronoma, which initially presented with hypokalemia and hypertension. They demonstrate successful outcomes with LA for aldosteronoma. Postoperatively, most of the patients reverted to normokalemia and showed improvements in hypertension. Removing aldosteronoma by LA has also been reported to have excellent results with low morbidity and mortality.
Some authors have even suggested that LA can be performed as an outpatient procedure in the manage-ment of aldosterone-secreting adrenal adenoma.
Hypokalemia is uniformly cured; however, persistent hypertension has been reported with return to- normal hormone levels postoperatively. The rates of postoperative hypertension are similar to those with open surgery and can be as high as 34%.
Almost all adrenal tumors can be resected by minimally invasive approaches. However, some limitations of LA include adrenal tumors larger than 6 cm, pheochromocytomas and malignant neoplasms.
It is still unclear whether laparoscopic resection is appropriate for large (>6cm) potentially malignant adrenal tumors because of the risk of incomplete resection and local recurrence. Some authors observe there were no significant differences between the median total anesthetic time, postoperative complications or postoperative hospitalization comparing the patients who underwent LA for tumors >6cm versus tumors <6cm. There was no evidence of local recurrence.
Although contemporary series suggest that minimally invasive surgery is a reasonable therapeutic modality for larger adrenal masses, LA for these large masses is a technically demanding procedure that should only be undertaken by experienced laparoscopic surgeons who are familiar with retroperitoneal anatomy and who are adept with vascular techniques in the event of an open conversion.
LA should be avoided if there is evidence of periadrenal infiltration preoperatively, and it is necessary to convert the patient to an open approach because of the difficulty in dissection caused by adhesion and fixation of the mass or local tissue reaction, and because of the risk of damaging the capsule of the potential malignancy.
Pheochromocytoma is a catecholamine-producing neoplasm of the adrenal medulla and is a major cause of correctable hypertension and its prevalence was 0.1-0.5% in a population of patients with hypertension. Intraoperative hypertensive or hypotensive episodes were often observed in these cases. The hemodynamic changes during LA for pheochromocytoma, compared with those during open surgery, have received considerable attention. There were no statistically significant differences between the LA and OA groups.
Series review has shown that the minimally invasive approach leads to similar or fewer hemodynamic fluctuations when compared with the open technique. This finding may be due to the added role of anesthesiologists during laparoscopy to better observe the operation and control the patients’ blood pressure.
Several comparative studies of LA versus OA for pheochromocytoma have been reported. Advantages of LA over OA were observed in terms of mean operating time, hospital stay, need for intensive care, intraoperative hypertension, intraoperative blood loss, postoperative analgesia and return to oral nutrition.
Laparoscopic removal of the adrenal malignancy raised the concern that the laparoscopic approach may result in inadequate removal of malignant adrenal tumors and increase the risk of local and port-site recurrences.
LA for primary adrenal malignancy can provide oncologic outcomes that are equivalent to open surgery but without an increased risk of carcinomatosis or port-site recurrence. Although long-term survival for up to 47 months with no recurrence has been reported, the underlying aggressiveness of this tumor has contributed to a rate of recurrence of 39.6% for the contemporary cases . An evaluation of open approaches revealed a similar or higher recurrence rate. When used to treat solitary metastases to the adrenal gland, LA provides oncologic outcomes that are equivalent to OA. LA for malignancy can be performed in appropriately selected cases with oncologic outcomes that are equivalent to open approaches, while providing advantages in terms of patient morbidity.
Caution must be taken to avoid damaging the tumor or leaving tumor tissue in situ because of the potential for local recurrence, port-site recurrence and carcinomatosis that can occur with these aggressive tumors.
Bleeding is the most common complication during and after LA, and accounts for approximately 40% of all complications. It may occur when a vessel or an organ is injured.
Other reported postoperative complications for LA include wound infection or hematoma, and hernia in the long-term, in addition to thromboembolic, urinary, gastrointestinal, pulmonary and cardiovascular problems. Complications specific to laparoscopy include severe hypercarbia and acidosis, port-site bleeding and hernia.
Conclusion:
LA is a safe, effective and minimally invasive approach that offers advantages such as better cosmetic, less blood loss, shorter hospital stay and rapid recovery for the treatment of adrenal tumors. So that LA is the gold-standard procedure for adrenal tumors, irrespective of whether the tumor is benign or malignant.